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Culture-Negative Periprosthetic Joint Infection: An Update on What to Expect
Timothy L Tan1, Michael M Kheir1, Noam Shohat1
1Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
Background:
Culture-negative periprosthetic joint infection (PJI) is a challenging condition to treat. The most appropriate management of culture-negative PJI is not known, and there is immense variability in the treatment outcome of this condition. The purpose of this study was to elucidate the characteristics, outcomes, and risk factors for failure of treatment of culture-negative PJI.
Methods:
A retrospective review of 219 patients (138 hips and 81 knees) who had undergone surgery for the treatment of culture-negative PJI was performed utilizing a prospectively collected institutional PJI database. PJIs for which the results of culture were unavailable were excluded. An electronic query and manual review of the medical records were completed to obtain patient demographics, treatment, microbiology data, comorbidities, and other surgical characteristics. Treatment failure was assessed using the Delphi consensus criteria.
Results:
The prevalence of suspected culture-negative PJI was 22.0% (219 of 996), and the prevalence of culture-negative PJI as defined by the Musculoskeletal Infection Society (MSIS) was 6.4% (44 of 688). Overall, the rate of treatment success was 69.2% (110 of 159) in patients with >1 year of follow-up. Of the 49 culture-negative PJIs for which treatment failed, 26 (53.1%) subsequently had positive cultures; of those 26, 10 (38.5%) were positive for methicillin-sensitive Staphylococcus aureus. The rate of treatment success was greater (p = 0.019) for patients who had 2-stage exchange than for those who underwent irrigation and debridement.
Conclusions:
The present study demonstrates that culture-negative PJI is a relatively frequent finding with unacceptable rates of treatment failure. Every effort should be made to isolate the infecting organism prior to surgical intervention, including extending the incubation period for cultures, withholding antibiotics prior to obtaining culture specimens, and possibly using newly introduced molecular techniques.
Level Of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Insights
Culture-negative periprosthetic joint infection (PJI) is common and has high failure rates. Two-stage exchange surgery shows better success than irrigation and debridement for treating PJI.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Biomedical Engineering
Background:
- Culture-negative periprosthetic joint infection (PJI) presents significant treatment challenges with variable outcomes.
- The optimal management strategy for culture-negative PJI remains undetermined.
- This study aimed to characterize culture-negative PJI, assess treatment outcomes, and identify risk factors for treatment failure.
Purpose of the Study:
- To elucidate the characteristics of culture-negative periprosthetic joint infection (PJI).
- To determine the outcomes of different treatment modalities for culture-negative PJI.
- To identify risk factors associated with treatment failure in culture-negative PJI.
Main Methods:
- Retrospective review of 219 patients with culture-negative PJI (138 hips, 81 knees) from an institutional database.
- Exclusion of PJIs with unavailable culture results; data collected via electronic query and manual record review.
- Treatment failure assessed using Delphi consensus criteria; level of evidence IV.
Main Results:
- Culture-negative PJI prevalence was 22.0% (suspected) and 6.4% (MSIS-defined).
- Overall treatment success rate was 69.2% for patients with over one year of follow-up.
- Two-stage exchange surgery demonstrated a significantly higher success rate (p=0.019) compared to irrigation and debridement.
Conclusions:
- Culture-negative PJI is a frequent condition with unacceptably high treatment failure rates.
- Efforts to identify the causative organism before surgery are crucial.
- Consider extending culture incubation periods, withholding antibiotics pre-operatively, and utilizing molecular techniques.
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